Mediastinal Tumor Treatment

Mediastinal tumors and cysts are benign or malignant masses that develop in the mediastinum region located in the middle of the chest cavity. These lesions are often asymptomatic and are detected incidentally during radiological imaging. Advanced examinations are required for a definitive diagnosis.

The classification of mediastinal masses is made according to their location as anterior, middle, and posterior mediastinum. While thymoma and lymphoma are common in the anterior mediastinum, nerve-origin tumors are usually located in the posterior mediastinum. Cystic structures are mostly congenital in origin.

Diagnostic methods and differential diagnosis are achieved with computed tomography (CT), magnetic resonance imaging (MRI), and biopsy when necessary. The size, structure, and invasion status of the lesion are decisive for differential diagnosis. Histopathological examination establishes the definitive diagnosis.

Treatment options and prognosis vary depending on whether the lesion is benign or malignant. Surgical resection is usually the first option; in some cases chemotherapy or radiotherapy may be required. In cases diagnosed early, treatment success and life expectancy increase.

What Is a Mediastinal Tumor?

A mediastinal tumor is an abnormal tissue growth that develops in the mediastinum region located between the two lungs and containing the heart, major vessels, esophagus, and trachea. It may be benign or malignant. Depending on its origin, it may arise from the thymus, lymph tissue, or nerve tissue. Symptoms vary depending on the size of the tumor and the pressure it exerts on surrounding structures. The diagnosis and treatment process requires multidisciplinary evaluation.

Where Is the Mediastinum Region and Why Is It Important?

My patients usually come thinking they have a problem in their lungs, but the mediastinum is not the lungs themselves; it is the “box” that remains between the two lungs. In thoracic surgery practice, we consider this region the most complex intersection of the body. Anatomically, its boundaries are very clear; the breastbone called the sternum at the front, the spine at the back, and the lungs on the sides.

The reason this region is so vital is the organs it contains. This is not just an empty space; on the contrary, it is like an armor protecting the most critical structures of the body working in a millimetric order. We can list what is in this narrow space as follows:

• Heart
• Aorta
• Vena cava vein
• Trachea
• Esophagus
• Thymus gland
• Lymph nodes
• Various nerves

As you can see, everything essential for the continuation of life is inside this box. That is why a mass developing here, even if benign by nature, carries the risk of compressing these vital organs as it grows. It may press on the heart, push the trachea, or compress the vessels. Therefore, we can also define mediastinal diseases as a “space limitation” problem, and we must closely monitor or treat any abnormal formation in this region.

What Symptoms Do Mediastinal Masses Cause in the Body?

The most interesting and sometimes most dangerous aspect of mediastinal masses is that they can progress quite insidiously. In a large proportion of the patients who apply to my clinic, there is actually no complaint. Most of the time they are detected incidentally during a chest X-ray taken for another reason, for example during a check-up, a job entry examination, or a simple flu infection. The mass may remain silent until it reaches a certain size or touches a critical point.

However, when the mass grows or acquires an aggressive character, it begins to disrupt the functioning of the body and sends some signals. These signals vary depending on what the mass compresses.

Common symptoms are as follows:

• Chest pain
• Shortness of breath
• Persistent cough
• Hoarseness
• Difficulty swallowing
• Fatigue
• Weight loss
• Night sweats
• High fever
• Drooping eyelid

Especially the drooping eyelid and muscle weakness I mentioned in the last item are very specific findings in mediastinal masses, particularly in tumors called “Thymoma.” This condition may be a precursor of a disease called Myasthenia Gravis. If night sweats, fever, and weight loss are prominent, then we think more about systemic diseases, for example lymphoma group disorders. In other words, your complaints are the most important clues we use while reaching the diagnosis.

Which Mass Appears in Which Region of the Mediastinum?

When we surgeons look at your scans, we can largely predict the name of the mass according to its location. Because each compartment of the mediastinum has a different tissue structure, and each tissue produces its own unique tumors. We virtually divide the chest cavity into three regions: anterior, middle, and posterior, and this separation forms the basis of our treatment plan.

The area we call the anterior mediastinum, just behind the breastbone, is the place where we most frequently see masses in adults. This is the home of the thymus gland.

Common masses seen in the anterior mediastinum are:

• Thymoma
• Thymic carcinoma
• Lymphoma
• Germ cell tumors
• Thyroid (goiter) extensions

The middle mediastinum is the region where the heart and trachea are located. Here we mostly encounter congenital developmental remnants or cysts.

Structures commonly seen in the middle mediastinum are:

• Bronchogenic cysts
• Pericardial cysts
• Enlarged lymph nodes

The posterior mediastinum is the groove just in front of the spine. Since this is where the nerve roots originate, almost all masses here are tumors originating from the nerve sheath. We call them neurogenic tumors. They usually follow a benign course but carry the risk of compressing the spinal cord. This regional distinction allows us to answer the question “what is this mass?” with about 70% accuracy.

Which Methods Are Used to Make a Diagnosis?

Our patients sometimes come with only a chest X-ray in their hands. However, a chest X-ray is insufficient to show a complex structure like the mediastinum in detail. Since this region lies behind the bones and the heart, it appears like a “shadow” on the X-ray. To understand what this shadow is, we need more advanced technologies.

The main method we use in the diagnostic process is contrast-enhanced Computed Tomography (CT). Tomography shows us the exact size of the mass, its borders, whether it contains fluid or solid tissue, and most importantly its relationship with the vessels at a millimetric level. This is our roadmap.

If the mass is close to the spine or if we are curious about its relationship with the nerves, we request Magnetic Resonance Imaging (MRI). MRI distinguishes soft tissues and nerve structures better than tomography. MRI is also very useful in understanding the content of cysts.

In suspicious situations, especially if there is a possibility of lymphoma or a disease that has spread throughout the body, PET-CT (Positron Emission Tomography) comes into play. This examination scans the entire body and tells us whether there is disease elsewhere and how active (hot) the mass is. However, PET-CT is not necessary for every patient; we decide this according to the character of the mass.

Is It Always Necessary to Perform a Biopsy Before Surgery?

This is the point where our patients are most confused and where we surgeons are most cautious. The general rule of medicine is “first take a sample, name it, then treat it.” However, in mediastinal tumors, especially when “Thymoma” is suspected in the anterior mediastinum, this rule does not apply; in fact, it may sometimes be dangerous.

Let me explain why: tumors such as thymoma usually remain inside a capsule (membrane). Our surgical goal is to remove the tumor completely without rupturing this capsule. If we try to take a sample by inserting a needle from outside before surgery (biopsy), we may pierce that capsule. This may cause tumor cells to spread along the needle tract and into the chest cavity. This situation may suddenly turn an early-stage disease into an advanced stage and increase the risk of recurrence. In medicine we call this the “seeding” risk.

Therefore, if tomography and clinical findings show us that this is a removable tumor, we remove the mass directly by surgery without performing a biopsy. In other words, diagnosis and treatment are performed simultaneously in a single procedure.

However, there are situations where performing a biopsy is mandatory:

Situations requiring biopsy are as follows:

• Suspicion of lymphoma
• Advanced-stage tumors
• Suspicion of germ cell tumor
• Inoperable masses

In these situations, since non-surgical treatments (chemotherapy/radiotherapy) will be planned, we must determine the exact diagnosis. In that case, instead of open surgery we use less damaging methods such as needle biopsy, EBUS, or mediastinoscopy.

What Are the Surgical Treatment Options?

In the treatment of mediastinal masses, surgery is often the most effective and definitive solution. We have different techniques for cysts that do not shrink with medication or tumors that must be surgically removed. In the past, we had to open the chest cavity with large incisions for these operations. However, today technology offers us much more comfortable options.

Surgical methods are basically divided into two: open surgery and closed (minimally invasive) surgery. Which method will be chosen depends entirely on the size of the mass, its location, and its adhesions to surrounding structures. Our priority is always “complete removal.” If we believe we can remove the tumor safely and completely with the closed method, we always prefer it.

Surgical methods are as follows:

• Video-assisted Thoracoscopic Surgery (VATS)
• Robotic Surgery (RATS)
• Median Sternotomy (Open)
• Thoracotomy (Open)

What Are the Advantages of the Closed Surgery (VATS) Method?

Video-assisted thoracoscopic surgery, commonly known as closed surgery, is revolutionary in thoracic surgery. In this method, instead of opening the patient’s chest from end to end, we create 1 to 3 small openings of about 1–2 centimeters between the ribs. Through these openings, we insert a high-resolution camera and long, thin surgical instruments. The surgeon performs the operation while watching the internal image on a large screen.

The comfort this method provides for our patients is invaluable. Its greatest advantage is minimal tissue damage since the ribs are not cut and the sternum is not opened.

The benefits of the VATS method are as follows:

• Less postoperative pain
• Shorter hospital stay
• Faster return to daily life
• Less blood loss
• Better cosmetic results
• Lower infection risk

Today we can safely remove thymomas of about 5–6 cm, almost all cysts, and most neurogenic tumors using this method.

Why Is Robotic Surgery (RATS) Preferred?

Robotic surgery represents the most advanced stage of closed surgery technology. Especially when working in a narrow, deep area filled with vital organs such as the mediastinum, the robotic system provides a precision that exceeds the capabilities of the human hand.

In robotic surgery, the surgeon is not at the patient’s side but at a console. We see the image in 3 dimensions and magnified 10–15 times. It feels as if we are inside that narrow area. The robot’s arms can perform maneuvers that the human wrist cannot; they can rotate 540 degrees around their axis and eliminate even the smallest tremor of the human hand.

These features provide a great advantage especially when dissecting tumors from nerves or removing the thymus gland over the heart. It reduces the risk of nerve injury, facilitates bleeding control, and allows us to perform a much more meticulous dissection. In short, robotic surgery is a technology that maximizes patient safety by increasing the surgeon’s comfort and control.

Should Benign Mediastinal Cysts Always Be Removed?

We encounter this question very frequently. “Doctor, my cyst is benign, it’s just a fluid-filled bubble, can it stay?” patients ask. Yes, bronchogenic or pericardial cysts are generally benign and their probability of turning into cancer is very low. However, our approach is generally toward removing these cysts.

There are several reasons for this. First, these cysts do not remain fixed in place; they tend to grow slowly over time. As they grow, they may press on the trachea and cause shortness of breath or cough. The second and more important reason is that these cysts may become infected. An infected cyst adheres to surrounding tissues and its surgery becomes much more difficult and risky.

The third reason is uncertainty. Sometimes a structure that appears to be a cyst radiologically may actually be a tumor with cystic characteristics. The only way to distinguish this definitively is to remove it and send it for pathological examination. Since we can remove these cysts in a short time and with low risk using closed methods (VATS/Robotic) today, we prefer to treat the patient permanently rather than letting them live with the stress of “will it grow?”

How Does the Recovery Process Progress After Surgery?

The recovery process of a patient undergoing mediastinal surgery varies depending on the method applied but is generally quite fast. If we have applied the closed method (VATS or Robotic), we can usually discharge our patients on the 3rd or 4th day after surgery.

The postoperative process proceeds as follows: when the patient leaves the operating room, a drain (thin tube) is inserted to remove the leakage accumulating in the chest cavity. This drain is usually removed within 24–48 hours. After the drain is removed, the patient can move much more comfortably.

Pain control is successfully managed with modern medications. The most important rule for us is “early mobilization.” We make our patient get out of bed the day after surgery and walk in the corridor. Walking helps the lungs expand, reduces the risk of clots, and accelerates recovery. After discharge, our patients can usually return to desk work within 2 weeks and to a more active life within 1 month. In open surgeries (sternotomy), since the bone must heal, this process takes a little longer, and movements that strain the sternum should be avoided for about 6–8 weeks.

What Is the Relationship Between Thymoma and Myasthenia Gravis?

About 30% to 40% of thymoma patients have a neurological disease called Myasthenia Gravis (MG). This disease occurs when the body produces antibodies against its own muscles and weakens them. It manifests with symptoms such as drooping eyelids, double vision, difficulty speaking, and rapid fatigue in the arms and legs.

The connection between these two diseases is so strong that in every patient diagnosed with Myasthenia Gravis we always perform a chest tomography to check whether there is a thymoma. If there is a thymoma, the treatment is definitely surgery. During the operation, not only the tumor but also the entire thymus gland and the surrounding fatty tissues (which may contain microscopic thymic islands) must be completely removed. This is called “Total Thymectomy.”

This surgery both eliminates the tumor and helps relieve the symptoms of the neurological disease (MG). However, the management of these patients is somewhat special; their sensitivity to anesthesia drugs is different and they must be followed very closely in cooperation with neurologists in the postoperative period.

What Risks Occur If the Mass Is Not Treated?

Some of our patients say, “Doctor, I am afraid of surgery, what happens if we leave it alone?” Although this is a very human fear, medical facts show us that waiting carries greater risks. Mediastinal masses are inside a closed box and the only direction in which they can grow is toward vital organs.

The risks of untreated masses are as follows:

• Causing rhythm disorders by compressing the heart
• Blocking major vessels and causing swelling in the face and neck (Vena Cava Syndrome)
• Narrowing the trachea and creating a feeling of suffocation
• Pressing on nerves and causing hoarseness or diaphragm paralysis
• Benign tumors turning malignant over time
• Rupture or infection of cysts
• Spread of the tumor to the lung lining and reduction of treatment chance

Instead of taking these risks, solving the problem radically with a planned and controlled surgery is always the safest way.

Frequently Asked Questions